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Gold Blue Cross Blue Shield Shared Cost 1500, a Multi-State Plan How it works Highmark Blue Cross Blue Shield West Virginia is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Companies. Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Health Services. Please note that information regarding the Patient Protection and Affordable Care Act of 2010 (“PPACA”), as amended, and/or any other law, does not constitute legal advice and is subject to change based upon the issuance of new PPACA guidance and/or change in laws. State laws may be applicable. Any review of materials, request for information, or application does not obligate you to enroll for coverage. The benefits listed are a summary. Please request the Certificate Booklet for details on benefits, conditions and exclusions. Providing your information is voluntary. We are committed to providing outstanding services for our applicants and members. If you require special assistance, including accommodations for disabilities or limited English proficiency, please call us at 1-877-959-2562 to request these free services (TTY/TDD users may call 711). Highmark Blue Cross Blue Shield West Virginia is Qualified Health Plan issuer in the Health Insurance Marketplace. P3161PSWVFront HighmarkBCBSWV.com 26158 (09/13) Blue Cross Blue Shield Shared Cost 1500, a Multi-State Plan helps keep your monthly expenses lower and offers fixed copays for some services. Here’s how: Many people don’t expect to use a lot of medical services but want fixed, predictable costs when they get care. With Blue Cross Blue Shield Shared Cost 1500, a Multi-State Plan, members have a fixed copay for some services, like doctor visits, prior to meeting the deductible. For less common services, individuals pay 100% of costs of most covered services until the deductible of $1,500 for individuals or $3,000 for families has been reached. After that, you pay copays and coinsurance until you reach the out-of-pocket maximum for the year. That amount is $3,500 for individuals or $7,000 for families. Then, Blue Cross Blue Shield West Virginia covers all your medical expenses when you receive covered health care services from network providers. Blue Cross Blue Shield Shared Cost 1500, a Multi-State Plan Explained Network Plan Details Out-of-Network Plan Pays You Pay Plan Pays You Pay Deductible – Individual N/A $1,500 N/A $3,000 Out-of-Pocket Limit – Individual N/A $3,500 N/A $7,000 Deductible – Family2 N/A $3,000 N/A $6,000 Out-of-Pocket Limit – Family N/A $7,000 N/A $14,000 Coinsurance plan pays after deductible 80% 20% 60% 40% 1 Preventive Care3 – Annual deductible and coinsurance do not apply to the Preventive Care services listed below Routine Annual Physical Exam 100% 0% Not Covered 100% Routine Annual Gynecological Exam 100% 0% Not Covered 100% Immunizations – Adult and Pediatric 100% 0% Not Covered 100% Routine Mammogram Screenings 100% 0% Not Covered 100% Preventive Medications 100% 0% Not Covered 100% 4 Illness or Injury Care Primary Care Office/Clinic Visit 100% after copay $35 copay 60% after deductible 40% after deductible Specialist Office Visit 100% after copay $45 copay 60% after deductible 40% after deductible Emergency Room Visit 80% after copay 20% after $150 copay 80% after copay 20% after $150 copay Urgent Care Visit 100% after copay $45 copay 60% after deductible 40% after deductible Prescription Drugs5 100% after copay Generic: $8 Brand: $45 Not Covered 100% Maternity Services 80% after deductible 20% after deductible 60% after deductible 40% after deductible Ambulance Services 80% after deductible 20% after deductible 80% after in-network deductible 20% after in-network deductible Inpatient Hospital Services 80% after deductible 20% after deductible 60% after deductible 40% after deductible Medical/Surgical Expenses 80% after deductible 20% after deductible 60% after deductible 40% after deductible Diagnostic Services6 (Lab, X-ray and other services) 80% after deductible 20% after deductible 60% after deductible 40% after deductible Therapy and Rehabilitation Services7 Spinal Manipulations Skilled Nursing Facility Care 80% after deductible 80% after deductible 80% after deductible 20% after deductible 20% after deductible 20% after deductible 60% after deductible 60% after deductible 60% after deductible 40% after deductible 40% after deductible 40% after deductible Mental Health Services Outpatient: 100% after copay; Outpatient: $35 copay; Inpatient: 80% after deductible Inpatient: 20% after deductible 60% after deductible 40% after deductible Substance Abuse – Rehabilitation Outpatient: 100% after copay; Outpatient: $35 copay; Inpatient: 80% after deductible Inpatient: 20% after deductible 60% after deductible 40% after deductible Substance Abuse – Detoxification 80% after deductible 20% after deductible 60% after deductible 40% after deductible Routine Eye Exam (Every 12 months) 100% 0% Not Covered 100% Pediatric Dental Exam/Cleaning: 100%; All other benefits: 50% Exam/Cleaning: 0%; All other benefits: 50% Not Covered 100% Pediatric Vision8 Exam: 100%; Frames/Lenses: 100% Exam: 0%; Frames/Lenses: 0% Not Covered 100% ou are responsible for out-of-pocket costs each Benefit Period up to a maximum amount shown. Thereafter, the Plan pays 100% of the Provider’s Allowable Charge during the Y remainder of the Benefit Period. This amount does not include amounts in excess of the Provider’s Allowable Charge. 2 Shared Cost and Comprehensive Care Family Deductible: For an Agreement covering more than one (1) family member, as each Member satisfies their individual Deductible, the Plan will begin to pay benefits for Covered Services for that Member for the remainder of the Benefit Period, whether or not the entire family Deductible has been satisfied. When the family Deductible has been satisfied, the family Deductible will be considered to have been satisfied for all remaining covered family members. No individual Member may satisfy the entire family Deductible. 3 The Highmark West Virginia Preventive Service Schedule is reviewed and updated periodically based on the requirements of the Patient Protection and Affordable Care Act of 2010, as amended, and the advice of the American Academy of Pediatrics, U.S. Preventive Service Task Force, the Blue Cross and Blue Shield Association and Medical Consultants. Accordingly, the frequency and eligibility of services is subject to change. 4 Certain limited prescriptions and over-the-counter drugs prescribed for preventive purposes. 5 Prescription drug copays for a 34-day supply (Retail): $8 generic; $45 brand; $95 non-formulary brand and non-formulary generic; specialty drug copays vary. The plan has a fourtier structure and utilizes the HCR Progressive Formulary on the Premier 2012 network. Mail order available. 6 Basic Diagnostic Services include four types of service: Standard Imaging Services, Laboratory and Pathology, Diagnostic Medical and Allergy Testing. Basic Diagnostic Services require one copay per date of service and type of service. Additional Basic Diagnostic Services are subject to deductible and coinsurance. Advanced Diagnostic Services include but are not limited to CAT Scan, CTA, MRI, MRA, PET Scan and PET/CT Scan. 7 Therapy visit limits include in and out-of-network visits. Physical Therapy, Occupational Therapy and Chiropractic Care are limited to 30 visits for each benefit per contract year for Rehabilitative and Habilitative services (combined). 8 Vision benefits utilize the Davis National Network. Pediatric Dental benefits utilize United Concordia’s Advantage Plus Network. P3161PSWVBack 1